Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
International Journal of Current Microbiology and Applied Sciences
ISSN: 2319-7706 Volume 5 Number 4 (2016) pp. 836-849
Journal homepage: http://www.ijcmas.com
Original Research Article
http://dx.doi.org/10.20546/ijcmas.2016.504.096
Exit-site Infections in Continuous Ambulatory Peritoneal Dialysis
Patients, Taif, Saudi Arabia
Khadijah Yousef AL-Aali*
Microbiology Department, Faculty of Medicine, Taif University, Taif, Sudia Arabia
*Corresponding author
ABSTRACT
Keywords
Exit-site infection,
ESI, infection;
Peritonitis,
Microbiology,
Peritoneal
dialysis,
Taif.
Article Info
Accepted:
22 March 2016
Available Online:
10 April 2016
Peritonitis is the most common infectious complication seen in peritoneal dialysis
(PD).exit site infection has been thought to predispose PD patients to peritonitis
Aim: to assesses exit-site infections in continuous ambulatory peritoneal dialysis
patients, Taif, Saudi Arabia. Method: A total 150 patients on peritoneal dialysis
were enrolled in this study, in Al-Hada Military Hospital Taif, Saudi Arabia, during
the 5 months period from August to December 2015.Swabs were taken and
processing under standard method. The age include from 35-60 years. Statistical
analyses were performed using the SPSS. Result: Bacteria were grown from
51(33.9%) of the 150 exit site swabs taken. There is statistical significant
difference between Sex/ gender and ESIs, in peritoneal dialysate patients, female
70(46.6%) P 0.04, while grade 3 P 0.04, and in 56-60 year 40 (26.6%) P 0.04.The
most commonly isolated organisms are, Staphylococcus aureus 15 (29.4%), MRSA
6(11.7%), E.coli 12(23.5%), Pseudomonas aeruginosa 9(17.6%). Acinetobacter
baumannii 3 (5.8%), and Serratia marcescens 6(11.7%). The susceptibility pattern
of bacteria isolated against 23 antimicrobial agents. All strains were susceptible to
some antibiotic, resistance was observed in some strains.Conclusion :This study
highlights the need for permanent evaluation by nurses on PD procedure performed
by patients, family members, such as proper hand hygiene and hygiene of the skin
near the insertion of the catheter.
Introduction
lead to peritonitis. The suggested
mechanism includes a movement of bacteria
from the exit site into the peritoneum via
peri-luminal migration along the PD catheter
tunnel. Although topical antibacterial agents
can prevent ESI and reduce peritonitis rates,
there is limited evidence exploring the
relationship between ESI and subsequent
peritonitis. Furthermore, the specific risk of
peritonitis related to different classes of
bacterial pathogens remains unknown (4).
Peritonitis is a leading cause of technique
failure and morbidity in patients undergoing
renal replacement therapy with peritoneal
dialysis (PD) (1,2). Although the frequency
of peritonitis has decreased over the past
decade
due
to
improvements
in
connectology, PD peritonitis still accounts
for approximately one-third of all technique
failures on PD (3). It is generally accepted
that exit site infections (ESIs) may directly
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
ESI in the immediate post–catheter
implantation period may depend on surgical
procedures, bacterial colonization, and
trauma.
Later
ESIs occur
almost
unpredictably,
possibly
related
to
mechanical irritation, hypersensitivity to
silicone rubber, hyperhydrosis, or reduced
tissue reactivity (5). The infection can
migrate to the outer and inner cuffs, spread
to the peritoneal cavity, and lead to tunnel
infection, peritonitis, and even catheter
loss(6).
there has been a change in the organisms
leading to exit-site infections. In a study
using gentamicin cream at the exit site (13),
the causes of exit-site infection were S.
aureus in 33%, other Gram-positive
organisms in 27%, yeast in 20%, sterile
culture in 13%, and Gram-negative
organisms
in
7%.Innovations
in
connectology and exit-site
bacterial
prophylaxis have led to a reduced incidence
of both peritonitis and exit-site infections in
patients on peritoneal dialysis. However,
exit-site infections are still a source of
morbidity in these patients, and the rate of
exit-site infections parallels the rate of
patient transfer from peritoneal dialysis to
hemodialysis.
During the 1990s, the overall probability of
developing an ESI was 33% – 46% at 1 year
and 59% – 70% at 3 years on continuous
ambulatory PD (CAPD). Peritonitis induced
by an ESI is found in 30% – 50% of
patients, and catheter loss may be as high as
15% – 57% (7,8).Systematic reviews
demonstrated that
the
method of
implantation, type of catheter, specific exitsite care protocol, and mode of dialysis
(CAPD, automated PD (APD)) did not
significantly influence peritonitis or ESI
rates (9). But mupirocin prophylaxis led to a
63% reduction in the risk of infection with
Staphylococcus aureus, with peritonitis
being reduced by 66% and ESIs by 62%
(10). The bacteria colonizing the exit site are
the same as those responsible for exit-site
infections, but somewhat different from
those causing peritonitis (11).
The International Society for Peritoneal
Dialysis (ISPD) has recommended that the
targeted rates for S. aureus-related catheter
infections be less than 0.05 episodes/patient
year at risk, with an overall catheter
infection rate of 0.2 episodes per patient
year at risk or less (14).These pathogens
demonstrate inducible beta-lactamase during
initial therapy, potentially leading to
empirical regimen failure, prolonged
peritoneal damage, and worse outcomes
(15). In the ANZDATA registry, the SPICE
group of pathogens accounts for26.9% of all
non-Pseudomonas GNB PD-associated
peritonitis, and Acinetobacter species are
responsible for, 20% of these cases (16,17).
Intuitively
thinking,
patients
with
Acinetobacter PD associated peritonitis
might have poorer prognoses compared with
the other Enterobacteriaceae members,
owing to their high antibiotic resistance
rates. However, past reports suggested just
the opposite, with technique failure rates of
9% (18) and 9.2% (19) in several studies. In
addition, several researchers proposed that
Acinetobacter peritonitis might occur with
an immunocompromised status (20). These
reports were all published nearly 2 decades
In a peritoneal dialysis population receiving
no antimicrobial prophylaxis, approximately
one-half of healthy exit sites are colonized
by Staphylococcus aureus, which also
accounts for over 50 % of exit-site
infections., Staphylococcus epidermidis
20%, Pseudomonas aeruginosa 8%, and
Escherichia coli 4%.Nasal carriage of S.
aureus, common among patients undergoing
peritoneal dialysis, also increases the risk of
recurrent exit-site infections (12).
With the widespread usage of prophylactic
antimicrobial applications at the exit site,
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
ago, and the temporal changes of clinical
characteristics, microbiologic features, and
outcomes of patients with Acinetobacter PD
peritonitis are unknown.
Materials and Methods
Study Population
This study included 150
patients on
peritoneal dialysis were enrolled in this
study, in Al-Hada Military Hospital Taif,
Saudi Arabia, during the 5 months period
from August 2015 to December 2015,
suffering various forms of Exit site infection
(SSIs).Official approval from directors of
the hospital has been obtained, after
clarification of the aim of the study and
assuring the confidentiality to them.
ESI with Pseudomonas is recognized as a
major complication of PD, with high risk of
catheter loss due to refractory/recurrent
infection or peritonitis. Felix et al. 2015 (21)
found Pseudomonas responsible of ESI
135(10.3%).There is remarkably little
literature about treatment outcomes in
patients with Pseudomonas ESI and there is
no standard treatment protocol. The reported
cure rate of Pseudomonas ESI with different
systemic antibiotic treatment regimens
ranges from 42 to 83% (22–23).
Antimicrobial prophylaxis is recommended
in addition to the normal daily exit-site care.
This approach likely works in part by
decreasing the number of potentially
pathogenic bacteria that colonize the exit
site; so, if trauma occurs, there are few
bacteria that can cause tissue invasion and
an infection. Antimicrobial prophylaxis
requires both a patient-oriented and centeroriented approach (24).
Specimen Collection
Two Swabs from peritoneal catheter exitsites were taken. The skin close to the exitsite of the catheter was also swabbed in a
circular manner. Both swabs were placed in
Stuart’s transport medium (Culturette
system, Becton Dickinson, Cockeysville,
MD, USA) and sent to the microbiological
laboratory. Immediately, swabs were plated
onto both 5% blood, McConkey, Chocolate
agar, Sabourad Dextrose Agar(SABDEX),
Saudi Prepared Media Laboratory, Saudi
Arabia, Riyadh (SPML), and incubated
aerobically at 37°C for 18–24 h,
International Society for Peritoneal Dialysis
guidelines advise the use of one to two
systemic antibiotics in case of Pseudomonas
ESI (25). There are no data or
recommendations
about
any topical
treatment of Pseudomonas ESI.
The demographic data of the patients and
the diagnostic criteria were collected by the
treating dialysis team. Other data including
associated risks factors (i.e. diabetes,
obesity, steroid therapy), use of prophylactic
antimicrobial agents, the type and duration
of dialysis, clinical evaluation of wound
(considered infected if there was pus
discharge or redness and swelling with
fever), and laboratory data (including Gram
stain, culture results, identification of the
bacterial isolates as well as antimicrobial
susceptibility) were recorded on a data
sheet.
Bernardini et al. (26) showed that topical
prophylaxis at the exit site with gentamicin
results in an equal reduction of ESI with
Gram-positive organisms compared with
mupirocin and also a reduction in ESI with
Gram-negative
organisms
including
Pseudomonas. The aim of the present study
was to study the exit-site infections in
continuous ambulatory peritoneal dialysis
patients, Taif, Saudi Arabia
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
Afterwards, the sensitivity to the antibiotics
was accomplished by disk diffusion test
performed for all the isolates by the method
recommended by Clinical and Laboratory
Standard Institute (CLSI). A suspension of
each isolate was made so that the turbidity
was equal to 0.5 McFarland turbidity
standard and then plated onto Muller-Hinton
agar (Saudi Prepared Media Laboratory,
Saudi Arabia, Riyadh (SPML).Antibiotic
disks (Oxoid) were applied to each plate.
After incubation at 37°C for 24 h, inhibition
zone size was measured. The patients
received the proper antibiotic thereafter.
Twenty three types of antibiotics were used
in both Gram-negative rod,and Grampositive cocci; Amoxicillin/ Clavulinicacid
(20/10μg), Cephalotin(30 μg), Oxacillin
(1μg),
Gentamicin
(10μg),
Sulfamethoxazole/
Trimethoprim
(1.25/23.75μg),
Ciprofloxacin
(5μg),
Clindamycin (2μg), Vancomycin(30μ),
Cefoxitin (30μg), Cefoxithin (30µg),
Ceftazidime(30μg), Cefotaxime (30μg),
Amikacin (30 µg), Ceftriaxone (30 µg),
Ceftazidime (30 µg), Ampicillin/Sulbactam
(10/10), Cefotaxim (30µg), Ticarcillin/
clavulanicacid
(75/10µg),
Imipenem
(50µg)), Cefepime (10µg), Ampicillin/
Sulbactam (10/10 µg), Aztreonam (30 µg),
Piperacillin/ tazobactam (100/10 µg).
Sample Processing
Direct examination of specimens: The first
swab was used to prepare two direct smears.
One was examined after adding 10% KOH
solution for fungal identification. The other
was stained by Gram stain for bacterial
examination and detection of PMNL which
is an important feature in case of bacterial
infection
rather
than
in
bacterial
colonization. Plates were incubated at 37° C
for 48 h. Bacteria were identified by means
of standard laboratory identification
methods. Oxacillin resistance testing was
performed for Staphylococcus aureus
isolates by use of oxacillin screen agar
(Saudi Prepared Media Laboratory, Saudi
Arabia, Riyadh (SPML). For each sample,
total bacterial counts were enumerated, and
the 3 most prevalent organisms were
recorded, in order of density.
Species Identification
Bacterial growths yields was identified
according
to
standard
conventional
procedures :
The species identification was based on
Gram-stain, catalase test, oxidase test, indole
test,
staphyloslide
test
kit
(BBL
Staphyloslide), sugar assimilation test, sugar
fermentation test.
Quality Control
To maintain the quality of data every sample
was processed in triplicates and every result
was cross checked by the principal
investigator. Enterococcus faecalis (ATCC
29212), Staphylococcus aureus (ATCC
24923), Streptococcus pyogenes (ATCC
19615),
E.coli
(ATCC
25922),
Pseudomonas aeruginosa (ATCC 27853)
were used as quality control throughout the
study for culture, Gram stain. All the strains
were obtained from the (ATCC, The
essential of live science research, USA)
Identified isolates were stored on nutrient
agar slant at room temperature for
subsequent susceptibility testing.
Commercial identification kits were used to
identify the isolates up to species level
Different type of API kits (Analytab
product, Plainview, N.Y), and Vitek
system, different card for identification of
Gram-positive bacteria, Gram-negative
bacteria, yeast (bioMérieux, Inc. Durham
NC,USA).
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
found in low percentage of 10 (6.6%), 6
(4%) respectively. Table 2.There is
statistical significant difference between
bacterial growth in ES swabs and ESIs, in
peritoneal dialysate patients in grade 3,
P0.04.
Data Analysis
Statistical analyses were performed using
the Statistical Package for the Social Science
(SPSS), Version 16 for Windows.
Continuous variables were summarized
using descriptive statistics in terms of
means, ± standard deviations, T.test; 95%
confidence intervals (95% CI), P value <
0.05 were considered significant.
The main group of the patient at peritoneal
dialysate patient was at age of 50-55 year
50(33.3%), flowed 56-60 year 40(26.6%),
while the age of 45-49 year gave the rate of
24 (16%),In contrast age 40-44, and 35-39
year presented in the percentage of
20(13.3%),16(10.5%), respectfully. There is
statistical significant difference between age
in years in ESIs patient at 56-60 year
40(26.6%) P 0.04.
Results and Discussion
This study included 150 patients, 10
child/boy (4.6%), 10 chilled /girl (4.6%),
adult/male 90 (41.4%), adult/female 107
(49.3%),their ages ranged from 35 years to
60 years. 51samples were positive for
culture 51(33.9%), and 99(65.4%) was
negative growth.
The grade of catheter-exit-site infection was
categorized
independently
from the
microbiological results following the ESgrade bacterial growth in ES swabs. Total
classification
of
Twardowski
(13),
Table4.The physician on duty during each
ambulatory visit documented the clinical
grading of infection in the patient’s records.
Exit-site infection Positive Negative grades
2, 3 and 4 were treated with local aseptic
ointment
and
intravenous
antibiotic
(vancomycin) was given for exit site
infection grades 3 and 4. Swabs were taken
before and 2 weeks after the end of the
antiseptic and/or antibiotic treatment.
Bacteria were grown from 51(33.9%) of the
150 exit site swabs taken; Male 80(53.3%),
while female 70 presented in rate of
(46.6%). Bacterial growth in ES swabs was
isolated from 51(33.9%) of these (Table 2).
In grade 0/1 exit-site infections, bacteria was
isolated 11 times (7.3%) of 150 swabs
taken, in grade 2positive culture was found
in 24(16%), while grade 3, and 4 were
presented in low rate of 10(6.6%), 6(4%),
respectively (Table 2).There was no
enrollment restriction based on age, gender,
end-stage renal diseases or previous renal
replacement therapy. There is statistical
significant difference between Sex/ gender
and ESIs, in peritoneal dialysate patients,
female 70(46.6%) P 0.04.
Bacteria were grown from 51(33.9%) of the
150 exit site swabs taken;
Staphylococcus aureus predominant bacteria
15(29.4%), in grade 2, (7,46.6%),while in
grade 0/1(4,26.6%), and in grade 3, and 4
presented in same range of (13.3%)
The grade of positive catheter-exit-site
infection was categorized independently
from the microbiological results following
the ES-grade bacterial growth in ES swabs.
The total positive culture 51(33.9%) out of
150 samples. The grade 2 presented in high
range was24 (16%), while grade 0/1
followed 11 (7.3%). In contrast grade 3,4
MRSA flowed in 6(11.7%) in grade 2
presented in high rate of (3,50%),while in
grade 0/1,3,and4 presented in same range of
1(16.5%)
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
E.coli isolated 12times (23.5%) in grade 2
presented in high rate of 7(58.3,50%),while
in grade 0/1,3,and4 presented in low range
of 2(16.6%), 1(8.3%), respectively.
trimoxazole,
gentamicin,
amikacin,
ciprofloxacin, ceftriaxone, ceftazidime,
ampicillin/
sulbactam,
Amoxicillin/
Clavulanic acid, Penicillin, Cephalothin. Al
stains showed sensitive to vancomycin,
clindamycin,
Pseudomonas aeruginosa isolated 9 times
17.6%, in grade 2 presented in high rate of
4(44.4%), while in grade 0/1,3,and4
presented in low range of 2 (22.2%), 1
(11.1%), respectively.
E.coli found to be resistant in 12 out of 51
cases
representing
23.5%,
while
Pseudomonas aeruginosa9 (17.6%). In
contrast Acinetobacter baumannii found to
be resistant in 3(5.8%), and Serratia
marcescens was resistant to 6 (11.7%).
E.coli was fully sensitive to ceftriaxone,
imipenem,
and
cefepime,
while
Pseudomonas aeruginosa was sensitive to
ccefoxithin, amikacin,
ciprofloxacin,
ceftriaxone,
ampicillin/
sulbactam,
ticarcillin/clavulanic acid, Acinetobacter
baumannii, and Serratia marcescens, were
sensitive to both antibiotics imipenem, and
cefepim.
Acinetobacter baumannii isolated 3 times
5.8%, in grade 0/1,2,3 presented in the same
rate of 1(33.3%),and not isolated from grade
4.
Serratia marcescens isolated 6 times 11.7%,
in grade 2 presented in high rate of
3(33.3%),while in grade 0/1,and4 presented
in low range of 1(16.6%). Table 5. Fig1.
Antibiotic Sensitivity
Disk diffusion method was performed to all
bacterial isolates causing infection. Among
these isolates, many were found to be
resistant to more than one antibiotic. The
susceptibility pattern of bacteria isolated
from ESIs patient against 23 antimicrobial
agents Table 5,6,7.
ESI should be considered with the
development of rash at the PD catheter exit
site ESI is a major risk factor for the
development and treatment of ESI are
essential (28).Skin infection at the catheter
exit site remains a relevant problem in PD
patients. Peritonitis episodes are usually
easily identified and counted, but exit sites
vary broadly in appearance from uninfected
to infected, making for a wide variation in
ESI classification and treatment between PD
units. This variation leads to imprecise
definitions of ESI, inconsistent monitoring,
and difficulties in interpreting study results.
In trying to avoid these difficulties, we
considered ESI only when signs of infection
were present and cultures were available
(29). The difficulty in microbiologic ESI
diagnosis is highlighted in that regional
commensal flora is often reported in
clinically evident ESIs. Total samples
enrolled in this study was 150.The incidence
of ESI in the present study was 51(333%),
Staphylococcus aureus found to be resistant
in 15 out of 99 cases representing 29.4%.
The result of this study revealed that,
resistant of Staphylococcus aureus to 15
antibiotic, and fully susceptible to oxacillin,
vancomycin, and penecillin. All strains were
susceptible to some antibiotic used in study,
and resistance was observed in some strains
of Staphylococcus aureus, the different
isolates’ resistance to various antibiotics in
percent study (Table 5). The antimicrobial
susceptibility pattern of MRSA isolates
against antimicrobial agents are summarized
in Table 6.More than 6(100%) of MRSA
isolates were resistant to oxacillin, co841
Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
which is higher than reported worldwide
incidence of Burkhard et al (30) on exit site
infections which reported, bacteria were
grown from 99 (26%).
after 2000, was 9 (64%)was the most
common species identified from the effluent,
and the leading causes of infection were
sterility break
and GI
microflora
translocation (33).
The result of present study revealed that,
Staphylococcus aureus predominant bacteria
15(29.4%), E.coli followed in isolated
12(23.5%), while Pseudomonas aeruginosa
isolated 9 times (17.6%). In contrast MRSA,
Serratia
marcescens,
Acinetobacter
baumannii were presented in the same low
rate of 6(11.7%).This result was in
agreement with the finding reported by
Burkhard et al (30), who found that, rate of
ESI was higher in grade 0/1 exit-site
infections, S. aureus isolates was isolated
15 (20%), and in pared with strains isolated
in lower infectious grades grade 2, 3 and 4,
S. aureus was found in 10 swabs (40%).
Previous studies have reported that age and
longer dialysis duration were not associated
with an increase in ESIs (34), but African
American and prior renal transplant patients
have an increased susceptibility to catheterrelated infections (35). Diabetic and
immunosuppressed patients are also at risk
for early S. aureus ESIs. Patients on
automated peritoneal dialysis (APD) were
found to have lower rates of peritonitis, but
not lower rates of ESIs or tunnel infections.
The importance of peritoneal dialysis
catheter exit site problems in determining
the long-term success of CAPD therapy has
recently been receiving increasing attention.
Detailed analyses of CAPD technique
failures have suggested that approximately
(36).
In other study, in adults, previously reported
ESI rates range from 0.05 – 1.02
episodes/patient–year. In contrast, Grampositive agents were responsible for most
pericatheter infectious episodes, and S.
aureus (at a rate of 0.46 per dialysis year at
risk) was the primary cause of ESIs (31). A
study indicated that the main risk factor for
the occurrence of catheter exit-site infection
is being a nasal staphylococcus carrier.
Thereby, it is reinforced the importance of
hand hygiene and use of masks by patients
and caregivers, while performing peritoneal
dialysis procedure (32).
There are limited data available to review
with regard to ESI in Saudi Arabian patients.
Al-Hwiesh et al.(37), reported that, Grampositive ESI occurred in 17.1% vs 10.2% of
patients (p<0.05), whereas 20% of and 5.1%
of patients (p<0.001) had Gram-negative
ESI in the 2 groups, respectively. While UrRehman et al.(38), found exit-site infections
occurred in 17 (30%) patients, Whereas
Ghulam et al. (39), reported that, the most
common causative organisms for peritonitis
were Pseudomonas (16%), Staphylococcus
epidermidis (16%), and Staphylococcus
aureus (7%).
In our study, found that E.coli was the most
frequent Gram negative agent 12(23.5%),
followed by P. aeruginosa 9(17.6%),while,
P. aeruginosa was the most frequent Gram
negative agent (8% – 12%), followed by
other Enterobacteriaceae (7% – 14%).Felix
et al.(2015) found that, Pseudomonas ESI in
PD patients from 135 patient presented in
low range of 14(10.3%) (21). Chia et al.
(2014), found that Acinetobacter baumannii
The International Society for Peritoneal
Dialysis (ISPD) recommends cleaning of PD
catheter exit site with antiseptic agent and
application of topical antimicrobials, such as
gentamicin or mupirocin, for the prevention
of ESI (14). Topical gentamicin has been
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Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
shown to reduce ESI and peritonitis due to
gram-positive and gram-negative organisms,
while, topical mupirocin mainly reduced ESI
due to gram-positive organisms. ESI is
typically diagnosed clinically based on the
finding of purulent or bloody drainage from
PD catheter exit site, surrounding erythema,
tenderness, and swelling. However, the
presence of skin rash and erythema without
drainage at the PD catheter exit site can be
also due to early infection, allergic reaction
to PD catheter material, or to mechanical
trauma (40).By analyzing the results
obtained in relation to sociodemographic
variables, it was observed consistency with
those found by the Brazilian Society of
Nephrology and by a cohort study named
BRAZPD, performed in the South and
Southeast
regions of Brazil(41).The
complexity of the peritoneal dialysis
procedure is recognized. In this sense, the
sociodemographic variables must be
considered in establishing the diagnosis of
cognitive, motor and affective skills of the
patients and/or caregivers by the nurses, in
order to prevent infectious complications in
PD (42).
Table.1 Socio-demographic Characteristics (Sex, Gender) of Patient at Peritoneal
Dialysate,Taif, N=150
Socio-demographic
Characteristics
Sex/ gender
Male
Female
Total
Mean 1.5/75; Std + 0.707
Frequency
N=150
%
P value
80
70
150
53.3
46.6
100
0.04
Table.2 Results of Bacterial Cultures from Exit-site (ES) Swabs (N=150)
ES-grade
0/1
2
3
4
Total
Bacterial growth in ES swabs (%)
Positive
Negative
11 (7.3%)
20 (13.3%)
24 (16%)
45 (30%)
10 (6.6%) P 0.04 14 (9.3%)
6 (4%)
20 (13.3%)
51(33.9%)
99 (65.9%)
Total
31 ((20.6%)
69 (46%)
24 (16%)
26 (17.3%)
150 (100%)
Table.3 Socio-demographic Characteristics (Age in Years) of Patient at Peritoneal Dialysate, Taif,
N=150
Socio-demographic
Characteristics
1- Age in years
35-39
40-44
45-49
50-55
56-60
Total
Mean 3/30; Std + 1.5/14.4
Frequency
N=150
16
20
24
50
40
150
843
Percent (%)
10.5
13.3
16
33.3
26.6
100
P value
P 0.04
Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
Table.4 Clinical Grading of Exit-site Appearance (ES 0–4), According to ref. (27 )
ES
0
1
2
3
4
Redness
no
< 2mm
< 2mm
< 2mm
< 2mm
Swelling
no
no
no
yes
yes
Pain
no
no
no
Yes
yes
Secretion
no
no
+
++
+++
Pus
no
no
+
++
+++
ES: Exit-site,+: present, ++: moderate, +++: intense
Table.5 Results of Positive Bacterial Cultures (N=150)
Positive ES swab (%)
ESStaphylococcus
grade aureus
N.15(29.4%)
0/1
4 (26.6%)
2
3
7 (46.6%)
2 (13.3%)
P 0.03
4
Total
2 (13.3%)
15
MRSA
N.6(11.7%)
E.coli
N.12(23.5%
Acinetobacter baumannii
N.3(5.8%)
Serratia marcescens
N.6(11.7%)
2 (16.6%)
Pseudomonas
aeruginosa
N.9(17.6%
2 (22.2%)
1 (16.6%)
1 (33.3%)
7 (58.3%)
2 (16.6%)
P 0.03
4 (44.4%)
2 (22.2%)
P 0.03
1 (33.3%)
1 (33.3%)
1 (16.6%)
P 0.01
2 (33.3%)
2 (33.3%)
3 (50%)
1 (16.5%)
P 0.03
P 0.05
1 (16.5%)
6
1 (8.3%)
12
1 (11.1%)
9
NI
3
1 (16.6%)
6
ES: Exit-site, NI:Not Isolated
Table.6 Antibiotic Susceptibility Pattern (%) of Resistant Staphylococcus aureus, and
MRSA Isolates in ESI Patients
Antibiotics
Amoxicillin/ Clavulanic acid
(20/10 µg)
Cephalothin (30 µg)
Oxacillin (1 µg)
Gentamicin (10 µg)
Amikacin (30 µg)
Ciprofloxacin (1 µg)
Ceftriaxone (30 µg)
Co-trimoxazole (1.2/23.8 µg)
Ceftazidime (30 µg)
Ampicillin/Sulbactam (10/10)
Penicillin (unit )
Vancomycin (30 µg)
Clindamycin (2 µg)
Resistant
Staphylococcus
aureus
N=15(29.4%)
3(20%)
Resistant
MRSA
N=6 (11.7%)
2(13.3%)
*S
3 (20%)
2 (13.3%)
1 (6.6%)
1(6.6%)
5(33.3%)
3(20%)
2(13.3%)
S
S
S
5 (83.3)
6(100%)
6(100%)
6(100%)
6(100%)
6(100%)
6(100%)
6(100%)
6 (100%)
6 (100%)
S
S
*S; sensitive
844
6(100%)
Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
Table.7 Antibiotic Susceptibility Pattern (%) of Resistant Gram-Negative Isolates in ESI
Patients
Antibiotics
Aztreonam (30 µg)
Cephalothin (30 µg)
Cefoxithin (30 µg)
Gentamicin (10 µg)
Amikacin (30 µg)
Ciprofloxacin (5 µg)
Ceftriaxone (30 µg)
Co-trimoxazole
(1.2/23.8 µg)
Ceftazidime (30 µg)
Ampicillin/Sulbactam
(10/10 µg)
Cefotaxim (30 µg)
Ticarcillin/clavulanic acid
(75/10 µg)
Piperacillin/tazobactam
(100/10 µg)
Imipenem (10 µg)
Cefepime (10 µg)
*S; sensitive
Resistant
E.coli
N=12
(23.5%)
1(8.3%)
3(25%)
1(8.3%)
2(16.6%)
1(8.3%)
1(8.3%)
*S
4(33.3%)
Resistant
Pseudomonas
aeruginosa
N=9 (17.6%)
1(11.1%)
2 (22.2%)
S
3(33.3%)
S
S
S
2 (22.2%)
Resistant
Acinetobacter
baumannii
N= 3 (5.8%)
2(66.6%)
3(100%)
3(100%)
2(66.6%)
1(4%)
2(66.6%)
2(66.6%)
3(23.8%)
Serratia
marcescens
N.6 (11.7%)
2(16.6%)
1(8.3%)
1(11.1%)
S
1(4.7%)
1(4.7%)
2 (33.3%)
1(16.6%)
3(25%)
2(16.6%)
1(11.1%)
S
2(66.6%)
2(66.6%)
1(16.6%)
2 (33.3%)
1(8.3%)
1(11.1%)
2(66.6%)
1(16.6%)
S
S
S
S
S
S
S
S
1(16.6%)
3(50%)
2 (33.3%)
1(16.6%)
3(50%)
1(16.6%)
2 (33.3%)
5(83.3%)
Fig.1 Frequency Distribution of Bacteria Isolated from Exit Site
The results obtained in this study showed
that, 33.9% of patients were admitted to the
dialysis program with a primary diagnosis of
unspecific kidney disease (43).This result
shows that, at the study site, the number of
patients on PD knowledge of the primary
disease is high. This may reflect the time
spent by the patient waiting for the first
medical consultation. In a study by Lo et al.
(44), 40.2% of ESI episodes were caused by
P. aeruginosa, and early removal of the
catheter was recommended. Kazmi et al.
(45) noted that, of 18 episodes of ESI caused
by P. aeruginosa, 15 (83%) resolved with
antibiotic therapy; only 3 (17%) required
catheter removal.
845
Int.J.Curr.Microbiol.App.Sci (2016) 5(4): 836-849
All isolates of S. aureus, and MRSA were
sensitive
to
oxacillin,
vancomycin,
clindamycin, also found resistant in some
strains. Table 6.Vancomycin remains the
first choice of treatment for MRSA and to
preserve its value, vancomycin use should
be limited to those cases where there are
clearly needed (46).The susceptibility
testing of the Gram-negative organisms; E.
coli showed that higher resistant to, cotrimoxazole,
cefotaxime,
while
Pseudomonas aeruginosa resistant to
cephalothin, gentamicin. In contrast,
Acinetobacter baumannii presented and
resistant to antibiotics,
ciprofloxacin,
ceftriaxone,
aztreonam,
cephalothin,
cefoxithin, Ticarcillin/clavulanic acid with
high percentage, and Serratia marcescens
showed high rate of resistant to cotrimoxazole,
cephalothin,
cefoxithin,
ticarcillin/ clavulanic acid
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How to cite this article:
Khadijah Yousef AL-Aali. 2016. Exit-site Infections in Continuous Ambulatory Peritoneal
Dialysis Patients, Taif, Saudi Arabia. Int.J.Curr.Microbiol.App.Sci.5(4): 836-849.
doi: http://dx.doi.org/10.20546/ijcmas.2016.504.096
849